A Systematic Critical Appraisal of Clinical Practice Guidelines in Juvenile Idiopathic Arthritis Using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) Instrument

<div><p>Objectives</p><p>The objectives of this review are to: 1) appraise the methodological quality of clinical practice guidelines (CPGs) in juvenile idiopathic arthritis (JIA) providing pharmacological and/or non-pharmacological intervention recommendations, and 2) summarize the recommendations provided by the included CPGs and compare them where possible.</p><p>Methods</p><p>A systematic search was performed. Three trained appraisers independently evaluated the methodological quality of the CPGs using a validated and reliable instrument, the Appraisal of Guidelines in Research and Evaluation II. Six domains were considered: 1) score and purpose; 2) stakeholder involvement; 3) rigor of development; 4) clarity of presentation; 5) applicability; and 6) editorial independence. The domains consist of a total of 23 items each scored on a 7-point scale. High quality CPGs were identified if they had a domain score above 60% in rigor of development, and two other domains.</p><p>Results</p><p>Of the three included CPGs, the Royal Australian College of General Practitioners (RACGP) and American College of Rheumatology (ACR) CPGs were considered to be of high quality, but the German Society for Pediatric Rheumatology was of lower quality. Domains one to four had high domain scores across the guidelines (mean (standard deviation)): 72.76 (13.80); 66.67 (9.81); 64.67 (7.77); and 87.00 (9.64), respectively. Lower scores were obtained for applicability (14.00 (5.57)) and editorial independence (43.44 (7.02)). Recommendations varied across CPGs due to differences in context, target audience (general practitioners, rheumatologists, and other multidisciplinary healthcare professionals) and patients’ disease presentations. Despite this variability, progression of pharmacological treatment did not conflict between CPGs. Recommendations for non-pharmacological interventions were vague and the interventions considered varied between CPGs.</p><p>Conclusions</p><p>Overall, recommendations were based on a paucity of evidence and weak study designs. Further research is needed on interventions in JIA, as well as higher quality CPGs to facilitate implementation of the best evidence-based recommendations in clinical practice.</p></div

Quality scores of included CPGs using AGREE II.

<p>ACR: American College of Rheumatology; GKJR: German Society for Pediatric Rheumatology; RACGP: Royal Australian College of General Practitioners; <math><mrow>x<mo>¯</mo></mrow></math>: mean; SD: standard deviation.</p><p>^aRating established using the AGREE II 7-point scale.</p><p>Quality scores of included CPGs using AGREE II.</p

Scope and context of the CPGs.

<p>sJIA = systemic JIA; MAS = macrophage activation syndrome; NSAIDs = non-steroidal anti-inflammatory drugs; DMARDs = disease modifying antirheumatic drug</p><p>Scope and context of the CPGs.</p

CPGs that considered pharmacological and non-pharmacological interventions.

<p>American College of Rheumatology; EULAR: The European League against rheumatism; NICE: National Institute for health and Clinical Excellence; OARSI: Osteoarthritis Research Society International; PGrip: People Getting a Grip on Arthritis RACGP: Royal Australian College of General Practitioners.</p

A Systematic Critical Appraisal for Non-Pharmacological Management of Osteoarthritis Using the Appraisal of Guidelines Research and Evaluation II Instrument

<div><p>Clinical practice CPGs (CPGs) have been developed to summarize evidence related to the management of osteoarthritis (OA). CPGs facilitate uptake of evidence-based knowledge by consumers, health professionals, health administrators and policy makers. The objectives of the present review were: 1) to assess the quality of the CPGs on non-pharmacological management of OA; using a standardized and validated instrument - the Appraisal of Guidelines Research and Evaluation (AGREE II) tool - by three pairs of trained appraisers; and 2) to summarize the recommendations based on only high-quality existing CPGs. Scientific literature databases from 2001 to 2013 were systematically searched for the state of evidence, with 17 CPGs for OA being identified. Most CPGs effectively addressed only a minority of AGREE II domains. Scope and purpose was effectively addressed in 10 CPGs on the management of OA, stakeholder involvement in 12 CPGs, rigour of development in 10 CPGs, clarity/presentation in 17 CPGs, editorial independence in 2 CPGs, and applicability in none of the OA CPGs. The overall quality of the included CPGs, according to the 7-point AGREE II scoring system, is 4.8±0.41 for OA. Therapeutic exercises, patient education, transcutaneous electrical nerve stimulation, acupuncture, orthoses and insoles, heat and cryotherapy, patellar tapping, and weight control are commonly recommended for the non-pharmacological management of OA by the high-quality CPGs. The general clinical management recommendations tended to be similar among high-quality CPGs, although interventions addressed varied. Non-pharmacological management interventions were superficially addressed in more than half of the selected CPGs. For CPGs to be standardized uniform creators should use the AGREE II criteria when developing CPGs. Innovative and effective methods of CPG implementation to users are needed to ultimately enhance the quality of life of arthritic individuals.</p></div

Quality Scores using AGREE II Instruments for included CPGs on OA.

<p>Domain 1. Scope and Purpose; Domain 2: Stakeholder involvement; Domain 3: Rigour of Development; Domain 4: Clarity of Presentation; Domain 5; Applicability Domain 6: Editorial Independence; Quality of CPGs: Using AGREE II scoring system :1–7; ACR: American College of Rheumatology; EULAR: The European League against rheumatism; NICE: National Institute for health and Clinical Excellence; OARSI: Osteoarthritis Research Society International; PGrip: People Getting A Grip on Osteoarthritis; RACGP: Royal Australian College of General Practitioners; mn: mean; SD: standard deviation.</p

The Included CPGs.

<p>ACR: American College of Rheumatology; EULAR: The European League against rheumatism; NICE: National Institute for health and Clinical Excellence; OARSI: Osteoarthritis Research Society International; PGrip: People Getting a Grip on Arthritis RACGP: Royal Australian College of General Practitioners.</p

A Systematic Critical Appraisal of Non-Pharmacological Management of Rheumatoid Arthritis with Appraisal of Guidelines for Research and Evaluation II

<div><p>Clinical practice guidelines (CPGs) have been developed to summarize evidence about the management of rheumatoid arthritis (RA) and facilitate the uptake of evidence-based knowledge by consumers, health professionals, health administrators and policy makers. The objectives of this review was to assess the quality of CPGS on non-pharmacological management of RA with a standardized and validated instrument - the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and summarize the key recommendations from these CPGs. Scientific literature databases from 2001 to 2013 were systematically searched and a total of 13 CPGs for RA was identified. Only a minority of AGREE II domains were effectively addressed by the CPGS. Scope and purpose was effectively addressed in 10 out of 13 CPGs, stakeholder involvement in 11 CPGs, rigor of development in 6 CPGs, clarity/presentation in 9 CPGs, editorial independence in 1 CPGs, and applicability in none of the CPGs. The overall quality of the included CPGs according to the 7-point AGREE II scoring system was 4.8±1.04. Patient education/self-management, aerobic, dynamic and stretching exercises were the commonly recommended for the non-pharmacological management of RA by the high-quality CPGs. The general clinical management recommendations tended to be similar among high-quality CPGs. Non-pharmacological management interventions were superficially addressed in more than half of the selected CPGs. CPGs creators should use the AGREE II criteria when developing guidelines. Innovative and effective methods of CPGs implementation to users are needed to ultimately enhance the quality of life of arthritic individuals. In addition, it was difficult to establish between strongly recommended, recommended and weakly recommended, as there is no consensus between the strength of the recommendations between the appraised CPGs.</p></div

Guidelines that considered pharmacological and non-pharmacological interventions.

<p>ACR: American College of Rheumatology, BSR: British society of rheumatology; EULAR: The European League against rheumatism; NICE: National Institute for health and Clinical Excellence; SIGN: Scottish Intercollegiate Guidelines Network.</p

Inter rater reliability study results for included CPGs ^a.

a<p>CP Gs =  clinical practice guidelines; P(G)MS = Patients’ (Guideline’s) Mean Square; RMS =  Rater’s Mean Square; EMS =  Error Mean Square; n =  sample size; K =  number of measurements; ICC =  intraclass correlation coefficient; CI =  confidence interval.</p>b<p>Temporary PMS, RMS, and EMS value.</p